Lower Lights Christian Health Center Streamlines Population Health and Care Management with Azara Healthcare
In two months, LLCHC decreased the number of patients with uncontrolled diabetes by nearly 9%
Established in 2002, Lower Lights Christian Health Center (LLCHC) is a faith-based, nonprofit Federally Qualified Health Center (FQHC), serving more than 13,000 residents across underserved areas of Central Ohio. Reflecting its deep commitment to quality, whole person care, LLCHC provides a comprehensive set of essential health services, including medical, behavioral, vision, dental, counseling, food and nutrition to its predominantly uninsured population, regardless of the ability to pay.
Today, LLCHC employs 165 medical professionals across six locations and accounts for nearly 60,000 patient encounters annually.
With a mission rooted in serving the nation’s underprivileged, underserved and uninsured, FQHCs must establish themselves as clinically focused and fiscally healthy organizations. As safety net providers of low- or no-cost care, community-based FQHCs receive reimbursements primarily from Medicaid and the Health Resources & Services Administration (HRSA) Health Center Program. As a result, their financial viability depends on their ability to provide care for geographically isolated, medically vulnerable and economically disenfranchised patients.
Like many progressive and growing FQHCs, LLCHC needed a modernized population health and care management partner to help reduce administrative burdens and manage the volume of scheduling, billing and practice management tasks associated with the patient’s care journey.
LLCHC care managers were inundated with manual paperwork, sticky notes, spreadsheets and siloed systems that hindered organizational efficiency, workflow, communication and collaboration. Care managers spent a tremendous amount of time searching between the organization’s electronic health record and other information systems to gain a complete view of at-risk populations.
To operate effectively, LLCHC needed a proven and automated solution that could deliver a seamless combination of clinical, claims, practice management and admission, discharge, and transfer (ADT) alert data, at an enterprise level. To accomplish that, the solution needed to be able to integrate and aggregate data from a technically diverse array of siloed systems.
Critical to LLCHC was selecting a scalable population health and quality improvement platform that could provide actionable data analytics and reporting to support care management, improve workflow documentation, limit use of unstructured EHR data, increase cost savings, and enhance patient outcomes.
Other goals of the implementation were to:
- Increase adoption and usage of data
- Reduce the number of patients with diabetes and an A1c greater than 9%
- Risk stratify populations to identify high-risk patients
- Improve billing for chronic care management
To that end, LLCHC selected Azara Healthcare’s population health solution, DRVS along with the Azara Care Connect (ACC) platform. Leveraging its decade long experience in community health, Azara’s solutions aggregate clinical, transitions of care and practice management data to identify high-cost or high-risk individuals, track clinical quality measures and outcomes, organize day-to-day tasks, and schedule follow-up appointments.
The ACC care management dashboard orchestrates and centralizes all available patient information from multiple systems, locations and sources to give care managers and other team members a comprehensive understanding of a patient’s care history and treatment plan.
Azara DRVS population health and quality improvement platform combined with Azara Care Connect's care management tools orchestrate and centralize available patient information, including:
- Identifying, tracking and closing care gaps
- Supporting transitions of care, patient outreach and interventions
- Documenting quality and accountability of case management
- Increasing incentive payments and identifying opportunities for lower costs of care
- Eliminating manual, time-consuming administrate and duplicate data entry
- Providing actionable data analytics and detailed reporting for cost improvements and forecasting
- Collecting and integrating various data streams, including claims, clinical, behavioral and social determinants
- Distinguishing best practices, benchmarks and comparative analytics, management
- Enhancing chronic care management and prenatal/postpartum retention
- Documenting time spent with patients, making it easier and more efficient to appropriately bill for chronic care and transition of care services
- Improving cross-team collaboration and communication
LLCHC went live on the Azara Care Connect platform in July 2020 and was able to reduce the manual review of charts by 12%. Further, within in two months, LLCHC saw an 8.8% decrease in its cohort of 381 patients living with diabetes with A1c levels greater than 9%.
“We were instantly able to recognize that the patients with diabetes cohort was poorly managed,” said Dr. Lynette Palmer, Senior Director of Quality for LLCHC. “With ACC, our two care mangers were able to get a good portion of our patients with diabetes under control really quickly. Azara’s solutions help demonstrate where we are moving, provides an overview of where we can improve, and what we can add to aid our efforts.”
According to a LLCHC Care Manager, the Azara Care Connect solution has been foundational in allowing her and her patients to understand how their A1c’s have fluctuated, highlight what clinical tasks and alerts are open, set care management goals, and illustrate improvements. Further, it fosters patient engagement and helped in reducing admissions to the ER while also preventing no-show appointments.
Use of the Azara DRVS population health solution provides accurate reporting and analytics to help manage patient populations and close care gaps where needed, while also supporting patient outreach and whole-person, value-driven care. The platform allows care managers to track their time spent with patients, making it easier and more efficient to appropriately bill for chronic care and transition of care services by identifying patients that have been billed and those who have not.
Care Manager Sonora Padgett says the solution supports the entire continuum – from quality reporting and workflow, to scheduling and patient experience. Another LLCHC care manager says the platform is a valuable tool for monitoring outcomes of care, completing tasks, and staying organized.
“Having the dashboard alone is my scheduler, I don’t have to have use sticky notes or rely on my memory. And more importantly, I don’t have to waste precious time searching in different systems. Now I spend that extra time with my patients.”